Failure to Assess and Supervise Resident with Wandering Tendencies Resulting in Elopement
Penalty
Summary
The facility failed to assess a resident for elopement risk upon readmission and did not identify the need for supervision despite the resident displaying wandering tendencies. The resident, who had diagnoses including dementia, unsteadiness on feet, and generalized muscle weakness, was readmitted to the facility and was not evaluated for elopement risk as required by facility policy. Documentation in the medical record and progress notes indicated repeated incidents of wandering, including attempts to exit the facility and entering other residents' rooms, but no updated interventions or care plan adjustments were made to address these behaviors. On the day of the incident, the resident was last seen sitting in a common area before being allowed to exit the facility's locked front door with the Medical Director, who was unaware of the resident's elopement risk. The resident was left unattended on the facility's front porch and subsequently walked along a busy road to a nearby dental office. Facility staff were notified by the dental office and retrieved the resident, who was then returned to the facility. Interviews with staff confirmed that the required elopement risk assessment was not completed at the time of readmission, and that staff responsible for completing the assessment did not do so. Further review revealed that the facility's policies required all residents to be assessed for elopement risk upon admission, quarterly, with significant changes in condition, and when behaviors indicated. However, the responsible staff did not complete the assessment, and the social services staff did not review relevant progress notes when completing the behavioral section of the MDS. Exit doors were also found to be unlocked when they should have been secured, and staff interviews confirmed lapses in supervision and communication regarding the resident's wandering and elopement risk.